0920-1154 Eligible Participant Screener - Focus Group

Form Approved

OMB Control No.: 0920-1154

Expiration Date: 3/31/2026

Eligible Participant Screener for Focus Group (to be conducted over the phone by recruiter)

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

Good news. You are eligible to participate in this project.

If you agree to participate in this project, we will ask you to take part in a web-based focus group. We will ask a series of questions about foodborne, waterborne, and fungal disease prevention. This focus group will take about 60 minutes. To thank you for your time, you will receive a $75 token of appreciation for your participation.

Do you have any questions?

Are you interested in participating in the focus group?

□ Yes (CONTINUE)

□ No, Okay, thank you for your time today. (STOP HERE)

CONFIRM NAME, DEMOGRAPHICS, EMAIL, AND PHONE

1. Could you please spell your first and last name?

I have a few additional questions to ensure we get a good mix of participants in this study.

2. In what ZIP code do you currently live? [ENTER FIVE DIGIT ZIP CODE]

3. Are you the parent or caregiver of a child(ren) under the age of 5 years who currently lives in your household?

   1. Yes

   2. No

   3. Prefer not to answer

4. Are you currently or have you been pregnant within the last year?

   1. Yes

b. No

2. Prefer not to answer

5. Are you: [Mark all that apply]

   1. Female

   2. Male

   3. Transgender, non-binary, or another gender

   4. Prefer not to answer

6. What is your race and/or ethnicity? [Select all that apply].

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Middle Eastern or North African

6. Native Hawaiian or Pacific Islander

7. White

7. What is the highest grade or year of school you completed?

1. Never attended school

2. Attended kindergarten only

3. Grades 1 through 8 (Elementary)

4. Grades 9 through 11 (Some high school)

5. Grade 12 or GED (High school graduate)

6. College 1 year to 3 years (Some college or technical school)

7. College 4 years or more (College graduate)

8. Graduate school

9. I prefer not to answer

10. I don’t know

8. What is your current occupational status? Would you say…?

   1. Employed full time

   2. Employed part time

   3. Unemployed

   4. Stay at home parent

   5. Student

   6. Retired

   7. Disabled

   8. Other:_______________

   9. Don’t Know/Not Sure [DO NOT READ]

   10. Prefer not to answer

9. Last year, in 2023, what was your total household income from all sources, before taxes?

   1. Less than $15,000

   2. $15,000 to $24,999

   3. $25,000 to $34,999

   4. $35,000 to $49,999

   5. $50,000 to $74,999

   6. $75,000 to $99,999

   7. $100,000 to $149,999

   8. $150,000+

   9. Prefer not to answer

10. Do you have a disease or condition that weakens your immune system? Examples include arthritis/rheumatism, asthma, cancer, chronic respiratory conditions such as emphysema or COPD, diabetes, heart disease, hypertension, stroke, HIV, lupus, inflammatory bowel disease, kidney disease, liver disease, multiple sclerosis, receiving an organ transplant, recent surgery or admission to a hospital/healthcare facility, and taking immunosuppressant medications like steroids.

    1. Yes

    2. No

    3. Don’t know/not sure

    4. Prefer not to answer

11. In the last 5 years, have you or a family member been admitted to:

    1. acute care hospital

    2. long-term acute care hospital

    3. skilled nursing facility (SNF) or a ventilator capable skilled nursing facility (vSNF)

    4. a long-term care facility

    5. prefer not to answer
       
       

12. How often do you consume or purchase new food or drink products based on potential benefits to your personal health and wellness?

    1. Daily [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    2. 1-2 times a week [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    3. 1-2 times a month [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    4. Never [INELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    5. I’ve never tried it, but I’m not opposed [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]
       
       

13. How often do you visit grocery stores that specialize in health food products?

    1. Daily [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    2. 1-2 times a week [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    3. 1-2 times a month [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    4. Never [INELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

    5. I’ve never tried it, but I’m not opposed [ELIGIBLE FOR HEALTH AND WELLNESS FOCUS GROUP; CONTINUE]

14. Do you agree with this statement? “I would rather try holistic/natural remedies before trying traditional medicine/drugs to improve my health”.

    1. Yes [Eligible for health and wellness focus group]

    2. No [Not eligible for health and wellness focus group]

    3. Not sure [Eligible for health and wellness focus group]
       
       

15. [FOR PARENTS] Have you ever made your own baby formula?

    1. Yes [Eligible for health and wellness focus group]

    2. No [Not eligible for health and wellness focus group]

16. If you are interested in participating in a discussion about health and wellness food products, or a discussion about foodborne, waterborne, and fungal disease prevention, please give us your contact information (interviewer will fill out contact information card) below. If you are chosen for the project, a team member will contact you to arrange a convenient time for the interview.

PARTICIPANT PREFERRED CONTACT INFORMATION (for recruiter use)
PARTICIPANT NAME:
Cell:	Home (other phone):
EMAIL (must be an email address that is used frequently):
Best time and way to reach:

Segmentation Table (FOR RECRUITER USE)

Population	Number of Focus Groups	Number of Participants
Pregnant Individuals (18+) (general population)	1	6-8
Older Adults (65+)	1	6-8
Caregivers of children <5	1	6-8
Immunocompromised	1	6-8
Hispanic individuals	1	6-8
Hispanic pregnant individuals	1	6-8
Individuals who are interested in health and wellness	2	6-8
Total	8	48-64